The online home of Paul McNamara: Nurse. Educator. Digital Citizen.

Tag Archives: nurturing

Man’s inhumanity towards man has been getting plenty of coverage lately – it might be time a good time to be reminded of men who demonstrate humanity.

Not quite 10 percent of nurses are male (please don’t call us male nurses – we’re nurses, but happen to be male).

Like our female colleagues, we’re spread across all aspects of health. Blokes nursing in Cairns include Stephen in Intensive Care; Adrian and Denis who work with elderly people; Bill the midwife; Andrew in orthopaedics; Colin who runs a medical ward; Sean who visits new parents and their babies in their homes; Greg and Clif who work with people battling mental health problems; Andy does mostly policy and administrative stuff; Steve and Scott on the local crisis team, and Nick who has spent a fair bit of time nursing out bush and is currently back in town.

There’s plenty of blokes nursing locally not mentioned (sorry fellas), but you get the picture – we pop up everywhere.

So, why nursing? I won’t presume to speak for other nurses of either gender, but I can tell you what I like about the profession – I like being useful.

It’s a peculiar privilege being a nurse. Peculiar because, for all its different guises and specialities, the basic job description is the same – try to be useful to people. It’s a privilege because nursing offers an amazing level of responsibility and intimacy.

It might sound more convincing if it wasn’t coming from a bald bloke with a bit of a beer gut, but nursing is a nurturing profession. The nature of our relationships with patients is therapeutic, but first and foremost it’s a human relationship.

We often have the privilege of being with people at very important stages of their lives, and we get the opportunity to show that nurses can be professional, skilled and caring.

I’m sure it’s not unique to nursing, and it’s certainly not unique to nurses who are male, but let’s not forget that there are daily demonstrations of man’s humanity towards man.

Final Notes

Back in 2003 a journalist from The Cairns Post invited me to submit an article for the My Say column (a daily feature presenting the views of a cross-section of the community). The article’s reference to man’s inhumanity to man is in the context of current events at the time – it was published during the second week of the war in Iraq.

As I was identified as an employee of a local hospital, at the time of publication the content of the article had to be approved by the hospital’s media department. The media department approved the article without changes to content.

In 2003 I should have used the phrase “man’s humanity towards mankind” instead of “man’s humanity towards man”. Sorry. I was tempted to correct it in this 2014 version, but decided it was more authentic to leave the original unaltered.

Anyway, I stumbled across the very-low-resolution JPG version of the article today and thought it might be worth reprising. Man’s inhumanity towards mankind is still dominating the mainstream media. This is a tiny, inadequate bit of counter-balance.

Stevie Jacobs is the pen name of a newly-minted Enrolled Nurse. The person behind Stevie is smart, experienced in life and has some awesome insight into the world of the student and new graduate nurse.

These words have been in my head and they needed to come out
(a blog post about suicide)

I am ‘Pro choice’.

I am a patient advocate.

I am a person advocate.

I support euthanasia.

I am pretty much of the opinion that if you have all the facts, figures and feelings figured out then you can go ahead and do pretty-much whatever you like. Even if it’s ‘bad’ for you. I can provide you with action plans and phone numbers and personal support, however ultimately, the choice my friend, is yours.

So when someone wants to kill themselves/suicide/take their own life (however you want to put it) what does my head feel about that? I’m not talking about obligations as a Health Care Professional, I’m talking about obligations as a human being. I can provide you with an ear to bend, a shoulder to lean on, I can find you professional help if you want, I can tell you that I don’t think you’re in a safe space and I want to get more support. For both of us. I can do all that. What I am stuck with is that if euthanasia is assisted suicide and I’m OK with that (OK meaning I won’t physically stop you nor judge you), does that mean I am ‘OK ‘ with someone’s suicide? Both have the same ending:, the removal of pain through the death of a person. I don’t know how my heart or my head feel about that.

Robin Williams was 63. That’s a long time to be living in pain. Yes, there are medications and therapies and support groups, but what if that starts to feel just all too much? That living is just all too much, a bit like ‘diabetic burnout’, where the person with diabetes basically gets fed up with ‘managing’ their diabetes and becomes unwell. That can happen with all chronic diseases. That can happen with mental health issues. Yes, some people have a depressive episode, it’s self-limiting and then they never have another one. Wonderful. For others, it just keeps on coming back, more painful than before.

To someone who is experiencing suicidal thoughts, suicide I can seem to be a rational method of pain relief. It’s the ultimate pain reliever for the person experiencing the thoughts.

For those left behind it can be devastating.

I can’t make up my mind. Do I have the ‘right’ to stop someone from suicide? I’m on the fence. The boundaries get blurred. I’ve experienced anxiety & depression, I’ve experienced suicidal thoughts & been ‘suicidally depressed’, I’ve had a family member suicide and I’ve known someone I followed on Twitter suicide. Which is a really fucking weird experience, quite frankly. Grief for someone who you ‘know’, but don’t ‘know’. 101 ‘What ifs?’. I could ‘see’ that something wasn’t right, but aside from checking in and offering an ear what else could I do? I’m at peace with those choices now, no longer haunted by ‘what ifs’. I’m sure that is not the same for their family and friends. I realised that what has stayed in my head is a photo of themselves they posted shortly before it happened. It’s their eyes. Their eyes haunt me. I can see something in their eyes I’ve seen time and time again. In my face. In the faces of others. I know those eyes so well. However good your mask is it’s in the eyes.

So, what to do? Who am I to tell anyone what to do? There isn’t really a clear answer. I think it’s really important to keep checking in on people: RU OK? I have RUOKed a few people and I will keep doing it. If it’s a ‘No’, and they express some ideas that worry you, it’s OK to ask “Do you have a plan?” If it’s a ‘Yes’, what then? Especially if you just don’t believe them. That’s trickier ground to navigate. I’m no expert on this. There are links at the end of this from people who are.

RU OK? It’s just a simple question. A simple, lifesaving question. I was on another planet from OK, and someone who barely knew me asked me that question.

It was like a thunderbolt.

It made me stop and think and choose to get help to make living less painful. Choosing to get help is hard. Getting help can be harder. What’s even harder is acknowledging that choosing to live is a conscious effort. It’s an effort. Accepting that medications and therapy and exercise and diet changes and avoiding triggers are now part of your life is an effort.

In time I hope that life will once again become effortless, but it might not.

Finally, after years of effort, I now think I am OK with that.

.

Post Script 1:

I wrote the above post a little while back. Normally when I have said all I have to say on a subject it doesn’t pop back in to my head. This post did. If I am honest, I have only scratched the surface. I have more to say. The way I write usually is like a good vomit on a night out: it all comes out in one go and it’s done and dusted and you’re up and dancing again. The other way I write is a bit more like a gastro bug: on and off with a bit of dry retching when you just can’t get it out. Then you’re done and you feel better.

Paul told me the ‘meta’ point of meta4RN is ‘talk about what you’re talking about’. So I guess that’s what I’m doing here. Rereading the above, reflecting on it and trying to work out quite what it is that I still feel I want to say.

We need to talk about mental health. We need to talk about suicide. We need to do it in a safe, appropriate and open way, but we do need to talk about it. Talking about it is hard. Talking about it can be terrifying for anyone. Talking about it when you’re a health professional is really damn hard. There are so many ‘what ifs’. What if they ‘lock me up’? What if they don’t? What if they think I’m not fit to practice? What if I lose my job? What if my colleagues find out? What if I have to be treated in the same hospital that I work in? What if…

I want to talk about how it feels to have suicidal thoughts. I want to talk about how it feels to be suicidally depressed. I’m not sure how to do that. I know that there are media guidelines for discussing suicide. As someone who is trying to describe a ‘lived experience’, I decided the best way for me to write was to let it all come out uncensored, and then give it to Paul to edit it using some of those guidelines and make it ‘safe’. I am in a safe enough space now to be brutally honest about how those suicidal thoughts feel, and far away enough from those thoughts to be able to talk about them without feeling ‘triggered’.

I can only speak for myself. For me there is a distinction between having suicidal thoughts and being ‘suicidal’ or ‘suicidally depressed’, as I have referred to it in the past. The thing about ‘suicidal thoughts’ is that the longer you have them the more rational they seem. For me suicidal thoughts are more of a hypothetical notion; it’s not something I am going to carry out. It’s an icy calm IF. IF things don’t get better, IF that was to happen, IF there isn’t another way out, IF the pain becomes unbearable, IF.

I know exactly how I would kill myself. I know exactly how I would spend the jackpot from a lottery win. I know exactly what I would get done if I had free access to plastic surgery. It’s all hypothetical.

It’s hypothetical. Until it’s not. Until I am suicidally depressed. Until I am in pain. Until the self-loathing I carry around with me every day takes over. Until I truly believe that the people in my life would be better off without me. Until I can’t see any way out aside from that way. And that place is not icy calm. It’s a messy, clinging on to something, anything to get through hour after hour, painful, emotional swamp. I feel emotionally swamped. I can’t think in a straight line. I can’t sleep. I can’t eat. The anxiety eats at my stomach. The panic attacks feel like I am dying of a heart attack. The after effects of which last for days. And nothing, nothing stops the pain. That’s how suicidal feels like for me. I know, however, that it is not what it looks like to other people. People see what they want to see. Even people who are trained to see more. I am brilliant at hiding it. I know how to put on my mask and polish up my armour. It is exhausting.

There are cracks in my armour, sometimes the mask slips. My fellow walking wounded can see though them, but for the most part the people I see every day wouldn’t know. I can make people feel so good about themselves. I can make people cry with laughter. Then, the second I am alone, the pain floods over me and I can barely breathe. I keep coming back to pain. It’s about pain. Not control, nor attention seeking, nor escape; in that moment it is about wanting that pain in my heart to stop. To. Stop.

It’s a horrendous place to live to be honest. It’s a half life. I had to choose to live better. To live for me. To get help – medications, counselling, CBT, exercise, diet. It’s a conscious choice. And what helped me make that choice was being asked ‘RU OK?’

I think I need to make it clear that I am talking about a period of over 10 years. I need to make it clear that I am talking about the past. I might write ‘I know’, but I suppose really it is ‘I knew’. Deciding to share this is a decision that has been easy, but it is a decision that I have made because these words have been in my head and they needed to come out. There are more things I could say, about specific attempts, specific feelings. However, I don’t want to share them. I think that’s OK.

I need to make it clear that I support ‘RUOK’ & WHO suicide prevention strategies. I need to make it clear that if you judge me negatively based on what I have written or if it changes your opinion of me, then that’s your thing, not mine. I’m not asking for agreement or understanding, but I do ask for kindness.

I was asked recently what the best thing in my life is right now. Aside from Nursing, the answer is the people in it. I know that my people love me, and accept ‘me’, and that’s enough.

Proposed changes to health funding in Australia’s 2014 Commonwealth Budget include direct costs (“co-payments”) to patients every time they see their GP or have pathology done, and an increase in the cost of prescribed medications. This extra revenue will be put towards medical research. Does the end justify the means meanness?

For some people with schizophrenia the only medication that keeps them well enough to stay out of hospital is clozapine. Clozapine was initially introduced in the early 1970s but was withdrawn within a few years because some people died while taking it. Although clozapine is the only effective antipsychotic for some people with schizophrenia, about 1% of those who take clozapine will develop agranulocytosis (a dangerous drop in white blood cells, especially neutrophils – the most abundant type of white blood cells). Left unrecognised and unmanaged agranulocytosis leaves people very susceptible to serious infections and, as happened back in the 1970s, can even lead to death.

Schizophrenia is a bugger of an illness. Onset of symptoms is nearly always in teenage years or early twenties. Schizophrenia is often misrepresented as split personality – that’s wrong – it infers that a person can choose or control their symptoms. The word schizophrenia has it’s roots in the Greek language, translated it means split mind – people do not choose to have a split mind. Symptoms vary between individuals, but very often people with schizophrenia will experience thought disorder (non-sequential, disorganised, confused thinking), delusions (beliefs, often unsettling and difficult to understand, that are not shared by others) and auditory hallucinations (sounds or voices that nobody else can hear, but which sound and feel very real to the individual experiencing them). If these symptoms are intense or frequent they can really make a mess of the individual’s ability to function successfully in school, university or the workplace. Consequently people with schizophrenia are over-represented amongst the unemployed and homeless.

Because schizophrenia is such a bugger of an illness and clozapine can be so effective at dampening-down the symptoms, in the early 1990s clozapine was made available again with some very strict protocols in place to keep the people taking it safer from serious side effects. When starting on clozapine blood tests are taken every week to check that the neutrophils/white blood cell counts don’t drop. It is built-in to the infrastucture of clozapine management – you can’t get a prescription until you’ve had a blood test and the doctor checks it against previous blood tests. If there are any problems with the blood tests the doctor will stop prescribing clozapine – no ifs, ands or buts. For about 1% of people the risk of agranulocytosis will outweigh the benefits of staying on clozapine.

For the person with schizophrenia taking clozapine this regular regime of blood tests, visiting the GP and getting a short-term prescription (there are no repeat prescriptions for clozapine) might be the difference between being in hospital and being at home, or (sometimes) being homeless and being at home. Once initial treatment is established, safe management of clozapine requires frequent blood tests, a new prescription every 4 weeks and regular visits to the GP.

The proposed budget changes include a $7 payment to see the GP, $7 fee for out-of-hospital pathology, and an additional $5 for each prescription medication. What are the benefits of making schizophrenia treatment more expensive? Are there any foreseeable problems?

We are being told by our government that Australia’s universal health coverage is not under threat. $7 to visit a GP costs the same as two beers says our treasurer. What a sneering, mean thing to say.

People with schizophrenia, like people with diabetes, chronic obstructive pulmonary disease (COPD) and other enduring illnesses, are already at a social and financial disadvantage. For the individual with schizophrenia whenever there is an increased intensity or frequency of delusions, auditory hallucinations and disordered thoughts they suffer terrible distress. The people who love and care for them share in this distress. Often an expensive hospital admission for a few weeks is required to bring the symptoms back under control and sort-out the social problems that a period of being out of touch with reality can cause: unpaid bills and rent may lead to loss of accommodation; neighbours, friends and family may be feeling uncomfortable having you home again; your self care and physical health may have deteriorated; your tobacco, alcohol and drug use may have increased; you may have come to the attention of the police.

Do the benefits of co-payments really outweigh the risks?

Final Notes

On Monday 19th May 2014 Joe Hockey, Australia’s Treasurer, will be appearing on Q&A. I have submitted this two-part question:

For some people with schizophrenia the only medication that keeps them well enough to stay out of hospital is clozapine.

Safe management of clozapine requires frequent blood tests, a new prescription every 4 weeks and regular visits to the GP.

What are the benefits of making schizophrenia treatment more expensive?

CoPayStories provides an avenue for patients and health professionals to share their perspective on the proposed GP co-payment – visit the website www.copaystories.com.au and/or follow @CoPayStories on Twitter.

For the purpose of this argument I’ve cited only one side-effect of one medication for one illness. I am aware that clozapine has more than one side-effect, and there are illnesses other than schizophrenia that require regular pathology, GP visits and prescriptions.

Thanks for visiting meta4RN: as always, you are welcome to leave feedback in the comments section below.

Those are the days when it feels like the time and space I have made to speak one-to-one to the patient* is in the middle of a sports arena. The patient and I walk into the middle of the empty playing surface and make our preparations for meaningful discussion, for emotional catharsis, for education, for counselling, for disclosure, for discovery, for therapy.

Then the grandstands of the arena start filling with people with loud voices. These people are not providing frontline care, so we would like to think of them as supporters. However, they all seem to think of themselves as coaches. They each have their own special area(s) of interest and shout well-meaning advice from their seats in the grandstand.

It gets very rowdy and distracting. So many supporters coaches. So many systems**.

Systems are what makes airlines so safe – apparently that’s why hospitals have become so system-focused over the last couple of decades. I think it is a bit silly that public health systems try so hard to align themselves with profit-making airline systems. The cost of a regional hospital redevelopment ($454m) is about the same cost as two Boeing 787s (source), However, they serve very different purposes: the hospital is filled with critically ill people aiming to become less unwell or die with dignity. Commercial jets are filled with tourists and business people going on a planned journey. The hospital is a place of unknowns: discovery, diagnosis, treatment, trials and strong, unpredictable human emotions. A commercial jet is a trumped-up bus that travels at a scheduled time on a scheduled route between clearly defined destinations, carrying only people who are wealthy and healthy enough to travel long distances.

Hospitals and airlines have such very different clients, expectations, control and outcomes – can they really teach-each other much about systems?

Nevertheless, I understand the rationale for systems, and will make no effort to argue against them. Still, wouldn’t it be nice if there was one healthcare system? As it stands in my workplace, the emergency department has a system (EDIS) that does not speak to the ICU system (MetaVision), which does not speak to the general hospital system (ieMR), which does not speak to the mental health system (CIMHA). And that’s just within one hospital – imagine how fragmented it gets when we start thinking of the primary healthcare and rural/remote outpatient sectors.

I understand that some of these systems, some of these competing demands, are very important – but not all of them are. For example, it is not important that a clinician spend time away from their patients to transpose a bit of information that is in one hospital system into another hospital system – this is a matter of dumb systems.

Which is why nurses and other clinicians know that sometimes the safest, most compassionate, and most ethical thing to do is to turn their back on the distractions created by dozens of disjointed systems, and make the priority to simply be with the patient.

In mental health over the last couple of decades nomenclature has changed from “patient” to “client” to “consumer” or “service user”. I understand the rationale for this – it is to move away from the passive (i.e.: “patient” as someone that the “expert” diagnoses and fixes) to participant (i.e.: “informed “consumer” of a service). In my current role I provide mental health assessment, support and education in a general hospital – the people I see are, in this context, first-and-foremost medical/surgical/obsetric hospital inpatients. It is these people’s physical health that had them admitted to an acute general hospital as “patients”, hence my use the word here.

**All the systems named in the “Systems Focused” cartoon are real, as is the claim that using each one is VERY IMPORTANT.

Tech Tip

I used an easy-to-use iPad app called Notes Plus to draw the cartoons. As you can see, my artistic skills have pretty-much plateaued since kindergarten, as has my spelling. Nevertheless, I think the cartoon might have been a little better and a lot easier to draw if I had used a stylus – that’s what I would recommend if you plan to do something similar.

End

As always, your thoughts/feedback is welcome in the comments section below.

Dear Reader: please don’t read this blog post if you are offended by strong swear words or find talk of suicide a trigger for unsettling/risky thoughts. Kind Regards, Paul.

Who is Going Behind the Curtains?

Working over Christmas and New Year made me especially cognisant of one of the peculiar privileges that we nurses have: we spend a lot of one-to-one time with the person who is medically/surgically recovering after a suicide attempt. My current role is Consultation Liaison Mental Health Nurse – a role that provides mental health assessment, support and education in a general hospital (more info about the role here). When the person is admitted to the general hospital after a non-fatal suicide attempt we are asked to be involved in planning and providing their care.

There are few things more privileged and more important than spending time with the person who is alive after deciding not to be. I do worry that this role is sometimes delegated to the least qualified (and lowest paid) member of frontline clinical care: the Assistant In Nursing (AIN) when there is “nursing special” in place (i.e.: when there are concerns that the person may abscond and/or harm themselves again).

Naturally, being an AIN does not mean you are incapable of sensitive, compassionate, safe care. I just think that “going behind the curtains” to assist in holding and containing the often very strong emotions of the person who has survived suicide is incredibly important. I don’t feel comfortable that someone without mental health qualifications or clinical supervision is tasked with sitting at the bedside for hours at a time. It may not be good for the either the person/patient or the AIN.

In clinical supervision we often explore the parallel processes and how they apply to our clinical work. When working in perinatal mental health I aimed for the therapeutic relationship to be a template for the parent-child relationship: kind and nurturing, responsive and interactive, empowering, educative and enjoyable. The idea being that, at some level, the qualities/values that inform the therapeutic relationship can then have a knock-on effect for the relationship the parent has with their baby. Not many perinatal mental health clinicians have an abrupt, cold, clinical style of interacting with their clients: they tend to be warm, gentle communicators.

When nursing the person who has survived suicide we need to think about parallel processes again. Julie Sharrock (a rock star of consultation liaison nursing) first introduced me to the phrase “holding and containing” as a part of the therapeutic relationship. Traditionally the notion of holding and containing has been attributed as a function of the inpatient setting/building: a place to keep people safe. Julie introduced it to me as a way to keep people safe, by reframing it as a concept for interpersonal therapy. That is, we nurses can assist and model the act of holding and containing difficult emotions.

For the person who has unexpectedly found themselves alive and in hospital after intending to end life, we may need to hold and contain the person physically for a short time, but (to my way of thinking) it is even more important to support the person to hold and contain their thoughts and feelings.

Thoughts are slippery, and prone to be dropped.

Feelings are brittle, and prone to cracking.

Holding and containing such difficult-to-secure, fragile things is fraught: the clinician needs their thoughts and emotions held and contained too. Its a parallel process: as I’ve discussed previously we need to nurture the nurturers.

Some of the most profound moments of my working life have occurred while supporting the person who has survived suicide.

The incredibly dark humour: “I’m such a fucking loser I can’t even kill myself properly!” said the very nice man. He was not laughing out loud, but smiling at the grim absurdity of his situation. He was alive, but physically worse-off than when he decided to die: now fractured, urinating through a tube, receiving fluids and antibiotics via an IV line. More wounds. More pain. Yet, despite the extra physical insults, he was pleased that he had survived.

The worry: “Is my brain OK? I feel really agitated and confused.” asked the lady who had been in intensive care for a few days. Her brain was OK in the long-term, the distress she was experiencing was mostly short-term stuff: delirium is really common amongst ICU patients. Hypoxic patients aren’t so lucky: they sometimes never recover the former function of their brain.

“You are the biggest fucking cunt that has ever existed in the whole world!”, said the man after being told he was unable to leave hospital. I was filling-in paperwork that would mean he was an involuntary patient as per the Mental Health Act. I didn’t think I was being particularly nasty. The mental health act is handy because there are times when I need to say, “It seems to me that you don’t have the capacity to keep yourself safe at the moment. So, I’ll take some of the responsibility of keeping you safe for now. Naturally, we will hand the job back to you when you come good.” Using that framework, filling-in the paperwork for the mental health act is sometimes the most nurturing thing I can do. That’s why i was genuinely surprised, not offended, when he said, “You are the biggest fucking cunt that has ever existed in the whole world!” I asked, “Really? Worse than Hitler?” He laughed and said, “Yeah, Definitely.” I laughed too. Take that Hitler.

The person who had two high perceived lethality, but fortunately non-fatal, attempts to take his life in the fortnight before we met reworded Shakespeare’s famous opening line to Hamlet. Instead of saying, “To be, or not to be, that is the question”, he said, “After what I have experienced in hospital, I now think that it is better to have a difficult life rather than no life at all.” I was so pleased to hear him think that way, and at the same time felt so sad for those people who do not have the opportunity to reconsider: those people that bypass the hospital wards and go straight to the morgue.

These are profound moments in the lives of people.

Nurses, myself included, have the peculiar privilege of being with the people who are experiencing the most important days of their life: the first few days of life that they planned not to have.

Let’s not take that peculiar privilege of nursing lightly.

In Closing

Talking and thinking about suicide can be distressing. Australians can access support via:

Outside of Australia and not sure where to get support? Google usually displays a red telephone icon and your country’s suicide support phone number when searching for a suicide-related topic.

As always, comments and feedback on the blog post is welcome. Suicide can be a sensitive topic to comment on, and this blog is the public arena; so, before wording your comment, please check-out this: Mindframe guide

A while ago I wrote about my most frightening workplace experience in a post called “Emotional Aftershocks“, which included a section titled “Zero Tolerance is Unrealistic and Unfair”.

Today, via a Tweet by Nicky Lambert I am reminded of how ridiculous the “Zero Tolerance” approach in hospitals is and (more importantly) have been introduced to an evidence-based alternative strategy that has recently been launched in the UK. To cut-out the middle-man and go straight to source of this pretty-cool strategy, click on the link: www.abetteraande.com

To subject yourself to my ideas and waffle, please read on…

What’s Wrong with Zero Tolerance?

A dumb, shouty poster.

It is inevitable that health services, hospitals especially, will have a large percentage of patients who have cognitive and perceptual deficits due to the very medical condition that has them bought them to the health facility in the first place. About 9% of the over-65s (a significant component of health service users) have dementia. Often these people will not have the cognitive capacity to discriminate between friend and foe, and will, at times, lash out to defend themselves against a perceived threat. All the shouty “Zero Tolerance” signs in the world will not make a difference to this. Why would we want to create a false expectation for staff?

As an aside, during the week I made use of Australia’s Dementia Behaviour Management Advisory Service (DBMAS) regarding strategies to use with a nursing home resident who had been aggressive. I found the service to be very user-friendly and helpful – if you provide care to people with dementia you should keep DBMAS in mind: dbmas.org.au

Huh? Of course people will get angry: it is an unavoidable, natural human emotion.

The “zero tolerance” concept is unfair because it is not reciprocated. We (that’s “we” as in “we the health system”) require patients and their loved-ones to be incredibly tolerant of us. Think waiting lists, physical discomfort, unplanned delays, unclear communication, unmet expectations, cancelled procedures, lack of privacy, lack of dignity, lack of control, lack of compassion, lack of progress… the list could go on. Can you find me a health facility where no patient has ever experienced these things?

Our health system relies on people being tolerant. This “zero tolerance” malarkey doesn’t allow for the reality that people in hospital are often having the most traumatic, frightening and disempowering day(s) of their life. It would be lovely for staff if everyone experiencing acute emotional distress expressed their emotions in a clear, calm and composed manner, but is it realistic?

A Smarter, More Sophisticated Approach

We need a smarter, more sophisticated way to manage difficult emotions in the health care setting. “Zero Tolerance” is jarringly out of step with the nurturing, caring, compassionate, altruistic qualities that most health professionals identified with when choosing their career. We need a new set of posters that are attuned to the needs of patients and the aspirations of health services and clinicians.

Of course, it’s not just posters on the wall that determine the quality and tone of the conversation. All health care workers should have an opportunity to reflect on their practice in a safe, structured way. As I’ve written about before (in “Nurturing the Nurturers“) clinical supervision (aka guided reflective practice) allows this to happen. There is an abundance of evidence that clinical supervision improves management of difficult encounters in health care settings – we should insist on it.

Nevertheless, posters and signage can play an important part in setting clear expectations. Just as they’re doing in UK accident and emergency departments, let’s take a proactive approach to preventing and managing distress. Part of that strategy should be moving way from the authoritative, uncompromising and negative campaigns of the past, to one that demonstrates and models respect.

This poster is my suggestion of the how we should set the parameters. Let’s not try to shut-down people from expressing distress. Instead, let’s invite patients and relatives to articulate their concerns before the emotions become so intense that they are difficult to contain.

Here’s the script to my poster:

Put your hand up and talk to us.

We don’t want you to feel distressed.

If you are feeling upset, frustrated or unsure about what’s happening please don’t bottle-it-up: talk to us.

One of the nurses, doctors or other hospital staff will listen to your concerns and try their best to help.

Warning: today I will take the risk of being ridiculed for over-sharing and being melodramatic (it’s a grand tradition amongst bloggers).

Crap Day at Work

Recently at work I spent a bit of time wondering whether I, one of my nursing colleagues, or one of the hospital patients or visitors was going to sustain a life-threatening brain injury at the hands of a man brandishing a fire extinguisher as if it were a weapon. Fire extinguishers are generally thought of as potentially life-saving devices. However, when a fire extinguisher is being held at shoulder height by a tall, fit, powerful young man on a violent rampage in a medical ward they don’t look like life-savers.

Fire extinguishers weigh 9kg and are made of steel. The fire extinguisher this man was holding looked a lot like a skull-cracking device to me. It was the most frightening workplace incident I have experienced.

I have been a nurse for 25 years. Like many nurses I have been struck while at work (39% of nurses have experienced physical violence according to this recent Australian survey, 36% worldwide says this quantitative review). I am lucky: I have only been hit by frail people with delirium or dementia, so have never been hurt – just surprised and amused. To illustrate: once, an elderly lady forgot I was the nurse making her bed, and suddenly started punching me (with the strength of a wet kitten) saying, “Stop it Malcolm! Don’t take my money from under the mattress and go to the pub again! You’re such a bastard Malcolm!” It was pretty funny – always wondered whether Malcolm was a memory from her past or a distortion of the present (probably a bit of both).

Zero Tolerance is Unrealistic and Unfair

I am not a fan of being abused or hit, but think that the “Zero Tolerance” campaigns that have popped-up in health services in Australia over the last 5-10 years are unrealistic and unfair.

This shouty “ZERO TOLERANCE NO EXCUSE FOR ABUSE” poster hangs in the main corridor of a medical ward, adjacent to the nurses station.

Unrealistic because it is inevitable that health services, hospitals especially, will have a large percentage of patients who have cognitive and perceptual deficits due to the very medical condition that has them bought them to the health facility in the first place. More than half of older persons admitted to hospital will experience delirium, and about 9% of the over-65s (a significant component of health service users) have dementia. Often these people will not have the cognitive capacity to discriminate between friend and foe, and will, at times, lash out to defend themselves against a perceived threat. We can look out for the warning signs and be proactive in protecting ourselves, but we can not expect to transfer responsibility for our safety onto someone who does not have the cognitive capacity to even keep themselves safe.

In the health system it is very common to be spending time with people who are having the most traumatic, frightening and disempowering day(s) of their life. It would be lovely for staff if everyone experiencing acute emotional distress expressed their emotions in a clear, calm and composed manner, but is it realistic?

The “zero tolerance” concept is unfair because it is not reciprocated. We (that’s “we” as in “we the health system”) require patients and their loved-ones to be incredibly tolerant of us. Think waiting lists, physical discomfort, unplanned delays, unclear communication, unmet expectations, cancelled procedures, lack of privacy, lack of dignity, lack of control, lack of compassion, lack of progress… the list could go on. Can you find me a health facility where no patient has ever experienced these things? Our health system relies on people being tolerant – this “zero tolerance” malarkey doesn’t allow for a bit of crap.

Instead of zero tolerance, it is more realistic to expect that patients will occasionally need to vent their emotions. Not just the pleasant emotions like love, joy, gratitude and kindness, but also the less comfortable human emotions like grief, anger, sadness, worry, despair, frustration, fear, pain and hate. For these emotions swear words are adjectives, a raised voice is empowering, tears are cathartic.

In “Nursing Ring Theory” (more info here: impactednurse.com) when someone is in a ring that is smaller than the ring you are in you offer support, compassion, care and skilful expertise. When someone is in a ring that is larger than yours you are allowed to ventilate your emotions with them. It is pure client centred care: everyone sends care going towards the direction of the patient and accepts that there will be crap coming out at times.

This acknowledgement of crap coming out is not an offer to hold out nurses and other health care workers as targets for abuse. That’s not OK. However, let’s shelf the zero tolerance crap: of course we’re tolerant of people ventilating their emotions. All we ask is that nobody is put at risk and those closest to direct patient care also have an avenue to safely ventilate their crap.

In ring theory care goes towards the patient and crap moves away from the patient. Proximity to the centre of the ring will be a fair predictor of the intensity of both care and crap.

Fire Extinguisher Guy*

Fire extinguisher guy is admitted to a medical ward for investigation of possible neurological disorder, but it might be something mental health related. So the Consultation Liaison CNC (me) spent a lot of time talking to fire extinguisher guy before the violent outburst, and again afterwards.

Fire extinguisher guy works hard, is creative, can be warm and funny at times; sadness, anger and tears bubble-up during our conversation then settle quickly. Talking to someone is both distressing and helpful, says fire extinguisher guy. He wants to get these strong, bouncing-all-over-the-place emotions under better control. Fire extinguisher guy’s experience of terrible abuse in childhood and his recent over-the-top cannabis and alcohol use wouldn’t be helping his labile hypomanic symptoms.

Fire extinguisher guy isn’t an unlikable person – he has a job, a car, a girlfriend, workmates, footy mates, other friends and a family. Fire extinguisher guy and the people who love him are all normal people. Fire extinguisher guy is one of the 20% of Australians who will experience problems with their mental health this year.

I am really grateful that fire extinguisher guy made the choice to direct his violence at property and not people. He had the capacity to make a very bad decision to hurt somebody; he chose not to. The only person physically harmed during this violent outburst was fire extinguisher guy himself: cuts from punching glass, bruises from punching and kicking windows, doors and walls of the medical ward.

I can’t figure out how long fire extinguisher guy’s violent outburst lasted. Replaying the scene in my mind I guess it was less than 2 minutes, but it’s like time measured in dog years… even though everything happened very quickly it somehow felt like slow motion too.

The fire extinguisher had been hurled into a storeroom doorway (THUD! CRACK!), the outburst was tentatively over, and fire extinguisher guy’s mum and i were lightly holding him and talking to him quietly when security arrived. Fire extinguisher guy allowed us to lead to him to an empty room and was cooperative with all of our suggestions and interventions. He apologised first to me, then to each of the other clinicians who provided care in those first couple of hours after the event. His apologies were heartfelt. He let the nurses, the doctor and the cleaner go about their business uninterrupted: his wounds were dressed, he accepted oral medications to dampen the intensity of his emotions, the blood and broken glass were cleaned-up, the other patients and visitors were reassured, detailed file entries were made, incident reports were filled-in, and negotiations between various members of the hospital’s multidisciplinary team were underway. The request for transfer off the medical ward could not be accommodated, but the insistence on two security guards overnight for staff and patient safety was.

Those of us up-close-and-personal to the incident took a couple of moments to exchange thoughts, but we tried not to get too bogged down in feelings at the time – it’s the beginning of the shift and fire extinguisher guy is just one of many patients on this busy medical ward.

Hole punched in the wall? No problem! One of the nurses covered the hole with this poster. Nurses are good at irony.

There is a hole in the wall that fire extinguisher guy created by punching it. One of the senior nurses on the medical ward covers the hole in with an anti-violence poster. We all laugh at the delicious irony and get on with our jobs.

As with the poster covering the hole, we crudely paper-over the cracks… it’s not fixing a problem, just covering it over… that’s good enough for now.

Emotional Aftershocks

In the days that follow I find myself a bit preoccupied at times thinking about the event. Get teary every now and then when I think of what could have happened: those skull-cracking thoughts are the worst bit… acquired brain injury anyone?

Skull-cracking thoughts are from my fear and imagination not from what actually happened.

That’s a good reminder. Keep saying that.

I’m OK: no flashbacks, no vivid dreams, no avoidance, no hyperarousal. I was back at work the next day (left a few hours early because I stayed back a few hours with fire extinguisher guy the night before). I’m seeing patients in the same medical and surgical wards, spending time with my very supportive colleagues.

I’m OK: I’m resisting the urge to quietly whisper to every fire extinguisher in the hospital, “Stay where you are my little red friend. Stay gently hooked on the wall. Do not allow yourself to be raised higher than my head. Please don’t go violently leaping about medical wards – people don’t like that THUD! CRACK! sound you make. Stay exactly where you are my little red friend.”

I’m OK: I’ve told the story a few times now – it’s losing its potency. The funny bit about the poster is good – every story needs a punchline (you’re welcome). The scary bit about the fire extinguisher is getting less vivid – it feels more like a story from the past now. It’s turning into a half-joke about fire extinguishers staying on walls exactly where they belong.

I’m OK: the only thing I’ve noticed is a bit of kummerspeck (great word, eh?). Kummerspeck is a German word that literally translates as “grief-bacon” – it refers to the weight gained through emotional over-eating. I’ve had to let my belt out a notch, and my favourite shirt feels too tight. Still going to the gym, so it must be the eating, Better keep an eye on that.

Yeah yeah yeah. If you’re so OK why are you blogging about it?

Part of the motivation is catharsis. Very self-indulgent, I know.

More importantly, senior clinicians should offer information and support that will empower and protect junior clinicians. Just a few days after the most frightening workplace incident I have experienced these two tweets popped-up on Twitter:

I do not know either of these people IRL (In Real Life), but I do feel a tremendous responsibility towards Emily, Dani and any other nearly-nurse who is as enthusiastic and passionate as these two. But what to say to Emily and Dani? How do we nurture them safely into our profession and keep their enthusiasm intact?

Referring to a patient as “fire extinguisher guy” is not a good example to set (more about that later – look for the red asterisk*).

As a senior nurse I should be supportive and encouraging to Dani, Emily and other enthusiastic nearly-nurses, and also be providing safety-tips and useful hints. I have two:

One: Make Like a Boy Scout

Be prepared.

Be prepared for some fantastic days at work where you’ll glide home feeling like you’re doing the most important and rewarding work that any one human can do. Those will be the days where you will use your knowledge-base, your skill-set and (most importantly) yourself to make a profoundly positive difference in somebody’s life. That person might never forget you.

Not every nurse gets exposed to violence or abuse, but you’ll see it up-close-and-personal through your patient’s eyes sometimes. Nurses do emotional labour: be prepared for the emotional aftershocks that come with the job. Find out about stress reactions and how to be pro-active in protecting yourself. I have an old, kind-of-dicky resource to share with you here, but you might find something better.

I am so angry that my nurse and midwife colleagues don’t have ready access to clinical supervision as a tool to reflect on practice and keep themselves (and their patients) safe. People say it would be too expensive to provide clinical supervision to every nurse who wants it, but there is huge cost already being paid. This cost (in terms of relationship stress, sleep disturbance, emotional trauma, anxiety, depression, substance use and kummerspeck) is being borne by individual nurses and the people who love them. Clinical supervision allows another way – through guided reflective practice many of these costs can be prevented.

I don’t see why looking after a nurse’s practice and emotional self through regular confidential support with a trusted colleague would be any less important than looking after a nurse’s back. Australian health facilities all have tools, time and training devoted to safe lifting, it is time to provide tools, time and training devoted to safe thinking.

Clinical supervision is available to mental health nurses, but not nurses in general hospital wards. In his epic novel Catch-22, Joseph Heller wrote:

People knew a lot more about dying inside the hospital, and made a much neater, more orderly job of it. They couldn’t dominate Death inside the hospital, but they certainly made her behave. They had taught her manners. They couldn’t keep death out, but while she was in she had to act like a lady. People gave up the ghost with delicacy and taste inside the hospital.

It is the nurses that make death and illness more neat, orderly and ladylike.

It is the nurses who paper-over the holes punched in the walls.

It is the nurses who stay on the ward to make sure that care keeps going in.

The nurses should be provided with an avenue to let crap out.

Guided reflective practice (aka clinical supervision) should be available for all nurses and midwives.

Closing Remarks

I would like to leave the story there because I have waffled-on for a long time already. However, it is necessary to address two tricky subjects raised in this blog post: [1] mental health and violence, and [2] my use of “fire extinguisher guy” when referring to a hospital patient.

Mental Health and Violence

Let’s get the facts straight:

the overwhelming majority of people who experience mental health problems are not violent: never have been and never will be

most violence is not perpetrated by people with a mental health problem

people who experience mental health problems are more likely to be victims of violence than perpetrators

I started specialist education in mental health nursing in 1993 and have spent most (not all) of my career working in clinical mental health nurse positions since then. I have never been physically assaulted by a person experiencing mental health problems. Never. However, earlier in the week there was a newspaper article reporting that “half of the nurses working on hospital psychiatric wards are themselves suffering from mental illnesses such as post-traumatic stress disorder, depression and anxiety.” I know that I have been more fortunate than some of my colleagues.

There are lots of myths and misunderstandings about mental health and violence. Please scroll to the bottom of the post for evidence-based resources and references.

Explanatory Note re the use of “Fire Extinguisher Guy”*

Using the term “Fire Extinguisher Guy” protects confidentiality and is, obviously, an irreverent, playful way to refer to a person. I don’t think this is wise for somebody creating a professional social media portfolio – somebody might think I’m being disrespectful.

Yet, here i am doing it anyway. Why?

Irreverence, humour and playfulness can be useful defence mechanisms: used correctly they can trivialise the other/traumatic events and empower the self. During the event I did what I could (very little) to assist this man to regain control and to keep himself and others safe from physical harm. It would not be useful to dwell on how powerless and vulnerable we all were at that time. I spent many hours talking to the man both before and after the event and treated him with kindness, respect and dignity.